A couple weeks after completing my anesthesiology residency, my first real job began. I was one of eight or nine solo practitioner anesthesiologists in a city of about 50,000. We all shared call coverage and performed anesthesia at the three hospitals and a freestanding, non-affiliated outpatient surgical center. A handful of us shared an office. The spouse of one of my anesthesiologist office mates performed all my billing.

My practice was off to a busy start. For the first two weeks, I essentially assumed the schedules of two of my anesthesiologist office mates, each of whom took a one-week vacation. For a short while after that, my case list was filled with procedures done by surgeons who now found it easier to schedule one-off cases with a new physician anesthesiologist.

Soon enough, though, my weeks developed a pattern: working with a general surgeon on Mondays; doing cardiac surgery on Tuesdays; being taught peribulbar blocks by an ophthalmologist, then using these in caring for his patients on Wednesdays; working with an oral surgeon on Thursdays; and keeping Fridays open for whomever needed an anesthesiologist.

For me, at the time, practice manage-ment centered around the three A’s of the practicing anesthesiologist: Availability, Affability and Ability. I was both anxious and confident. The chairman of my residency program at the University of Texas Medical Branch, Dr. James F. Arens, had once stated that the worst thing that can happen to a new anesthesiologist is to have a bad patient outcome in the first couple of weeks. Still, my training and education had been extensive, and my abilities were proven. Those first two weeks did not see any early mishaps, all my patients did well and the surgeons apparently approved of my skills.

Another facet of practice management was proper billing for my anesthesiology services. In our training program, all the residents learned how to use the Current Procedural Terminology codes to fill out billing sheets. This prepared me well for my private practice. At the end of each day, I would code all my own cases and then turn the paperwork in to the woman who did my billing. Within a couple of months, there was a steady income stream resulting from all those cases.

That income was a blessing, as it enabled me to relatively quickly pay off the $25,000 loan I had taken out to set up the practice: scheduling service, office overhead, billing fees, medical liability insurance, beeper services, etc. Back then, capitated payment was just starting to come to Texas, and there was little penetration of managed care in my practice area. Even Medicare payment was relatively good for me, as I had no pre-existing billing history with Medicare. If my memory serves me, it was in 1990 that Medicare payment changed significantly, falling to the typical 34 percent of a standard charge.

My professional life seemed relatively simple back then, especially when reviewed through a contemporary lens. Even so, my practice did begin to reflect the strain of a busy anesthesiologist. And one surgeon used my inability to be present one day as a reason to no longer book cases with me. Here’s how that played out: One Tuesday there were no cases scheduled for me with the cardiac surgeons. I confirmed with them that there were no cases, and feeling the need to earn my keep, accepted a relatively short case for a 7 a.m. start at another hospital. A bit later, as I was in the middle of my case, I received a beep from the cardiac surgeon. Sure enough, he had found and posted a case. I was his Tuesday anesthesiologist, so he was upset that I could not drop what I was doing and come immediately to care for his patient. He found another anesthesiologist who was free, and he never booked another case with me. Through my own practice management decision, I had lost the majority of my Tuesday work because I had not met the first of the three A’s – Availability – of the practicing anesthesiologist, at least not for this surgeon.

Now, those of us in positions to manage practices contend with myriad stressors. One of these influences is choosing which practice model best fits the needs and expenses of a certain practice arena – the model in my teaching hospitals continues to evolve and is different than that in my outpatient surgery center. Certainly, a large influence is the impending changes of the Affordable Care Act, and as a state institution, we also have to deal with state budget issues. There are more and new issues every day, some related to physician or employee management, others related to recruiting schedules, etc. ASA is here to help you. Attend PRACTICE MANAGEMENT 2014 this month. Learn from the experts.